Print version ISSN 0034-7094
Rev. Bras. Anestesiol. vol.52 no.3 Campinas May/June 2002
Meningitis after combined spinal-epidural analgesia for labor. Case report *
Meningitis después de técnica combinada para analgesia de parto. Relato de caso
Carlos Escobar Vásquez, M.D.I; Raquel da Rocha Pereira, M.D.II; Tomio Tomita, M.D.III; Antonio Bedin, TSA, M.D.IV; Renato Almeida Couto de Castro, TSA, M.D.V
IME1 do CET/SBA, SAJ
IIAnestesiologista do CET/SBA, SAJ
IIIAnestesiologista do CET/SBA, SAJ; Intensivista do Hospital Municipal São José
IVAnestesiologista; Co-responsável pelo CET/SBA
VAnestesiologista; Responsável pelo CET/SBA. Presidente da SBA
BACKGRAUND AND OBJECTIVES: Meningitis
is a serious complication, although rare in regional anesthesia. This report
aimed at presenting a case which evolved to meningitis after combined labor
CASE REPORT: Laboring patient, 25 years old, second gestation and previous c-section. Combined labor spinal-epidural analgesia was induced with double-puncture. Twenty-four hours later she presented with headache at rest, fever and mild chills, which regressed with symptomatic medication. Headache worsened in the 5th day. There were vomiting and neck pain in the 10th day. Symptoms became more severe in the 13th day. Lumbar puncture was performed. Clinical history and CSF analysis were compatible with bacterial meningitis.
CONCLUSIONS: Combined labor spinal-epidural analgesia is very close to being the ideal technique. Care must be taken with the sterile technique to induce spinal blockade. The reported complication has occurred without an apparent technique failure and is inherent to techniques risk-benefit ratio.
Key words: ANESTHETIC TECHNIQUES, Regional: combined spinal-epidural; COMPLICATIONS: infection, bacterial meningitis
JUSTIFICATIVA Y OBJETIVOS: Meningitis
es una complicación grave en anestesia regional, no obstante, rara de ocurrir.
El objetivo de este relato es mostrar un caso de una paciente que evolucionó
con meningitis después de realización de analgesia de parto por la
técnica combinada (raqui-peridural) con dupla punción.
RELATO DEL CASO: Paciente con 25 anos, segunda gestación y cesariana anterior, en trabajo de parto. Fue realizada analgesia de parto por la técnica combinada (raqui-peridural) con dupla punción. Después de 24 horas presentó cefalea en reposo, picos de hipertermia, calofríos discretos, que mejoraron con medicación sintomática. En el 5º día la cefalea peoró. En el 10º día surgieron vómitos y dolor en la nuca. En el 13º día los síntomas pasaron a ser más intensos. Fue realizada punción lumbar. La historia clínica y el examen del líquor fueron compatibles con meningitis bacteriana.
CONCLUSIONES: La técnica combinada (raqui-peridural) para analgesia de parto está próxima de lo ideal. Cuidados con la técnica de anti-sepsia son necesarios para realización de bloqueos espinales. La complicación presentada ocurrió sin la aparente falla en la realización de la técnica, siendo una cuestión que es inherente al riesgo - beneficio que la técnica proporciona.
Although rare, meningitis is a severe regional anesthesia complication 1-3. It is characterized by an infectious or non-infectious meningeal process. Bacteria, viruses, fungi, among others (tuberculosis, spinal hemorrhages), may cause central nervous system (CNS) infections, most of them through blood flow. Infection points in brain structures (ears, paranasal sinuses, mastoid), osteomyelitis in brain bones, accidental, surgical or anesthetic accidents, may break natural barriers and cause CNS infections. Although in theory any bacteria may cause meningitis, only three bacteria are responsible for approximately 90% of all bacterial meningitis: Neisseria meingitidis, Streptococcus pneumoniae and Haemophilus influenzae.
Clinical presentation is composed of three major syndromes:
1. Intracranial hypertension syndrome: severe
headache, nausea, vomiting and a certain degree of mental confusion;
2. Toxemic syndrome: with general symptoms such as high fever, discomfort and agitation;
3. Meningeal irritation syndrome: classically, neck stiffness. Keming, Brudzinski and Lasegue Signs may also be present.
Sporadically, there is no more than one sign or symptom. According to the etiological agent, clinical findings may differ. So, petechial or purpuric skin rash is found in approximately 50% of patients with meningococcemia. Approximately 20% of acute bacterial meningitis may present with seizures. In 25% of cases symptoms start abruptly, as a fulminating disease. Mortality is high in such situation. More frequently, meningeal symptoms resolve in one to seven days.
This report aimed at presenting a case of bacterial meningitis after combined spinal-epidural blockade in an obstetric patient.
Female patient, 25 years old, second gestation and previous c-section, was admitted to the maternity in labor, 3 cm of cervical dilatation and intact membrane. After obstetric and anesthetic evaluation, labor analgesia was suggested. According to our routine, analgesia was induced with the combined spinal-epidural technique and double puncture. Spinal puncture was performed with a disposable 27G Quincke needle and 5 µg sufentanil were injected. Epidural catheter was inserted with a 16G Tuohy needle. Since the catheter presented with leakage points, it was removed and a new catheter was inserted. Labor did not evolved as expected and C-section was indicated due to head-pelvis disproportion, six hours after beginning of analgesia. Anesthesia was induced through the catheter by the continuous epidural technique and 200 mg (20 ml) ropivacaine and 10 µg (2 ml) sufentanil were injected. There were no intercurrences. In the first 24 postoperative hours, patient referred headache at rest, fever peaks and mild chills. Symptoms improved and patient was discharged three days after admission under symptomatic medication. At home, 5 days after surgery, headache worsened with sporadic dizziness. After 10 days there were vomiting and neck pain. After 13 days, symptoms were even worse and only then the patient looked for medical advice, with neck stiffness, severe headache, fever and vomiting. After ruling out gynecologic and obstetric diseases, patient was hospitalized with diagnostic hypothesis of meningitis.
CSF was collected and presented turbid. Material was sent to lab analysis and antimicrobial therapy was started with ceftriaxone. CSF analysis had the following results:
· Aspect and
color: slightly turbid;
· Cells: 2480 cells: 8% mononuclear and 92 segmented. Gram: negative;
· Proteins: 45 mg.dl-1;
· Glycorrhachia: 28 mg.dl-1
· Chlorides: 673 mg.dl-1;
· Negative culture: China ink: negative; Lues: negative.
Other lab tests:
· Blood count:
leucocytosis of 20,900 cells with bands 1%; polymophonuclear 88% (left shift);
· Hemoculture: two negative samples
· Normal Urinalalysis. Uroculture: negative.
Twenty-four hours after beginning of therapy, patient had no longer complaints and was discharged after 10 days. Neurological evaluation has not shown sequelae.
Although rare, meningitis may appear after combined labor analgesia 4. Three mechanisms may be involved: hematogenic path of a distant focus; contaminated equipment or drugs; and sterile technique failure5,6.
The most probable hypothesis for meningeal irritation would be inadvertent epidural catheter contamination during its handling 7. Since the catheter presented a leakage during insertion, this could be the cause of contamination. At a certain point, the catheter must have suffered a trauma that would have caused this storage defect and, why not, its contamination. In Maternidade Darcy Vargas, we have an average of 170 C-sections a month. Since 1994, we perform routine and on demand labor analgesia. We perform in average 180 analgesias/month without ever seeing such complication. Since 1996, we moved to the combined analgesia technique. To date, 5800 analgesias using this technique were induced in our hospital and this has been our first meningitis case after such procedure. It must be reminded that the patient evolved to C-section soon after and more anesthetics were epidurally administered to induce surgical anesthesia.
In our case, 13 days elapsed from beginning of symptoms to diagnosis, what is not common. Studies have shown meningitis up to 25 days after the procedure 6. The inability to obtain the isolated germ does not discard bacterial pathology 4.
Classicaly, bacterial meningitis presents with increased CSF pressure due to difficult reabsorption in the spinal space, characterizing a communicating hydrocephalus. CSF is turbid. The increased number of cells (pleocytosis) is the major CSF analysis abnormality. Cytomorphological differential shows an absolute predominance of polimorphonuclear neutrophyls. Bacteria can be found through Grams bacteriological analysis. Cultures are positive in approximately 70-90% of samples. Total proteins are high. Glycorrhachia is very low and tends to zero. As a rule, hypoglycorrhachia indicates infection. Chlorides are in general decreased although more often in tuberculosis meningitis.
Meningitis should be seen as medical emergencies and promptly treated to minimize sequelae. The treatment is based on protocols about the suspicion of meningitis genesis (Table I), very often empirically until lab confirmation, which sometimes is negative for germs.
New CSF samples should be collected throughout the disease, depending on patients clinical evolution. When there is a favorable response, treatment with antibiotics should not go beyond 10 to 14 days.
In addition to clinical evolution differences, aseptic meningitis has different CSF characteristics: clean, mildly increased proteins, normal glucose and increased lymphocytes 9. In our case, clinical data and CSF analysis have confirmed the diagnosis of bacterial meningitis. Adequate response to therapy was observed after 24 hours of antibiotics.
Although not ideal, the combined technique is getting very close to it 10,11. For promoting good quality analgesia, it is conquering its space, and undoubtedly a prominent one. Care with the sterile technique is important and it should be very thoroughly performed 1,12. However, if the patient has a complication without apparent technical failure, this will be a risk-benefit ratio inherent to the technique 13. Some authors do not believe that the combined technique increases the incidence of meningitis but that, as any other technique invading the spinal space, it may cause such complication 4.
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Submitted for publication June 26, 2001
Accepted for publication October 30, 2001
* Received from Maternidade Darcy Vargas, CET/SBA do Serviço de Anestesiologia de Joinville. Joinville, SC